Review Article Carpal Instability Nondissociative

Abstract Scott W. Wolfe, MD Carpal instability nondissociative (CIND) represents a spectrum of Marc Garcia-Elias, MD conditions characterized by kinematic dysfunction of the proximal carpal row, often associated with a clinical “clunk.” CIND is Alison Kitay, MD manifested at the midcarpal and/or radiocarpal , and it is distinguished from carpal instability dissociative (CID) by the lack of disruption between within the same carpal row. There are four major subcategories of CIND: palmar, dorsal, combined, and From the and Upper Extremity adaptive. In palmar CIND, instability occurs across the entire Service, Hospital for Special proximal carpal row. When nonsurgical management fails, surgical Surgery, New York, NY (Dr. Wolfe and Dr. Kitay) and the Hand and options include arthroscopic thermal capsulorrhaphy, soft-tissue Upper Extremity Surgery, Institut reconstruction, or limited radiocarpal or intercarpal fusions. In Kaplan, Barcelona, Spain dorsal CIND, the capitate subluxates dorsally from its reduced (Dr. Garcia-Elias). resting position. Dorsal CIND usually responds to nonsurgical Dr. Wolfe or an immediate family management; refractory cases respond to palmar reefing member has received royalties from Extremity Medical and Elsevier; is a and/or dorsal intercarpal capsulodesis. Combined CIND member of a speakers’ bureau or demonstrates signs of both palmar and dorsal CIND and can be has made paid presentations on behalf of TriMed and Small treated with soft-tissue or bony procedures. In adaptive CIND, the Innovations; serves as a paid volar carpal are slackened and are less capable of consultant to or is an employee of inducing the physiologic shift of the proximal carpal row from Extremity Medical, OsteoMed, and Small Bone Orthopedics; and serves flexion into extension as the ulnarly deviates. Treatment of as a board member, owner, officer, choice is a corrective osteotomy to restore the normal volar tilt of or committee member of the New the distal . York Society for Surgery of the Hand. Dr. Garcia-Elias or an immediate family member has received royalties from Tornier; is a member of a speakers’ bureau or he terms carpal instability disso- Conceptually, radiocarpal ligament has made paid presentations on Tciative (CID) and carpal insta- insufficiencies are CIND problems, behalf of OsteoMed; serves as an bility nondissociative (CIND) were in which the entire carpus is translo- unpaid consultant to SBI; and first proposed by Dobyns et al1 in cated in a palmar, dorsal, radial, or serves as a board member, owner, officer, or committee member of the 1985 to distinguish between two ma- ulnar direction, often without a International Federation of Societies jor classes of carpal instability. CID proximal row dissociation. However, for Surgery of the Hand. Neither is characterized by instability be- because their clinical features are so Dr. Kitay nor any immediate family tween bones within a single carpal dissimilar from those observed in pa- member has received anything of 2,3 value from or has stock or stock row. CIND is characterized by dys- tients with a proximal carpal row options held in a commercial function of the entire proximal car- dysfunction, they are not discussed company or institution related pal row, manifested at either the ra- here. directly or indirectly to the subject of diocarpal , the midcarpal joint, this article. The typical features of CIND were or both. first identified in 1934 by Mouchet J Am Acad Orthop Surg 2012;20: 575-585 These disorders are frequently as- and Belot, who referred to symptom- sociated with a clinical “clunk.” atic laxity of the carpus as “snapping http://dx.doi.org/10.5435/ 4 JAAOS-20-09-575 CIND may be distinguished radio- wrist.” Since then, several investiga- graphically from CID by the lack of tors have identified subcategories of Copyright 2012 by the American Academy of Orthopaedic Surgeons. a separation or bony break within CIND with subtle differences in pre- the proximal carpal row (Figure 1). sentation and demographics. The no-

September 2012, Vol 20, No 9 575 Carpal Instability Nondissociative

Figure 1 joint, tenderness to palpation over radial deviation and prona- the ulnar carpus at the triquetroham- tion. The examiner passively trans- ate joint, and painful clunking that lates the distal carpal row and occurred with pronation and ulnar central metacarpals in a palmar di- deviation.4 Lichtman et al6 initially rection, and the wrist is then ulnar- referred to this disorder as ulnar deviated by the examiner. As the midcarpal instability until 1993, wrist is brought into ulnar deviation, when these authors renamed it pal- a dramatic clunk is noted as the mar midcarpal instability to distin- proximal carpal row pops into ex- guish it from reports of dorsal mid- tension (Video 2). The driving force carpal subluxation. Because the of this clunk is the articular surface instability occurs across the entire of the distal carpal row. The helicoi- proximal carpal row and is not iso- dal surface of the hamate forces the lated to dysfunction of either the ra- hyperflexed triquetrum into sudden diocarpal or midcarpal joints, pal- extension, pulling the attached lu- mar CIND (or CIND-VISI) is the nate and scaphoid into extension more descriptive and inclusive term. with it.9 The clunk may or may not be painful. Illustration of carpal instability nondissociative, which represents Clinical Presentation instability at the radiocarpal joint, Patients with symptomatic palmar Pathomechanics the midcarpal joint, or both joints (outlined in red). Unlike patterns of CIND typically report a painful When a normal wrist deviates from a instability in carpal instability clunk while performing activities radial-deviated to ulnar-deviated dissociative, there is no break that require ulnar deviation, such as posture, the three bones of the proxi- between bones within either the pouring liquids. Generalized liga- mal carpal row rotate from flexion proximal or distal carpal rows. mentous laxity is a common finding into extension. Two entities ensure in this population, and many pa- that this rotation is smooth and pro- tients do not recall a specific injury gressive: the palmar midcarpal liga- menclature used to describe these associated with the onset of symp- ments and the coordinated function subcategories has been variable and toms. A volar sag of the ulnar carpus of the flexor carpi ulnaris and ex- confusing at times, but the clinical is often noted on visual inspection tensor carpi ulnaris muscles. Par- entities encompassing CIND can be (Figure 3). The condition is often bilat- ticularly important are the most understood by dividing them into eral, despite presentation with symp- proximal fibers of the triquetral- four major groups: palmar CIND (or toms predominantly in one wrist. hamate-capitate ligament and the CIND-VISI [volar intercalated seg- Persons with congenital ligamentous anterolateral scaphotrapezium liga- mental instability]), dorsal CIND laxity (most frequently women, chil- ments (Figure 5). As the wrist devi- (or CIND-DISI [dorsal intercalated dren, and adolescents) or with patho- ates ulnarly, these two ligaments be- segmental instability]), combined logic ligament laxity (eg, Ehlers-Danlos come progressively taut and pull the CIND, and adaptive CIND (Figure syndrome, cutis laxa) commonly have proximal row smoothly into exten- 2). asymptomatic or minimally symptom- sion. The coordinated contraction of atic palmar CIND. the flexor carpi ulnaris and extensor Palmar CIND Most patients with palmar CIND carpi ulnaris muscles also helps ex- demonstrate the classic catch-up tend the proximal row by realigning The most common type of CIND is clunk (Figure 4) as the proximal car- the flexed triquetrum into a more ex- the palmar type, or CIND-VISI. This pal row pops from a flexed posture tended posture. The results of several disorder was first characterized as a into an extended posture during ra- cadaver-sectioning studies suggest true clinical syndrome by Lichtman dial to ulnar deviation (Video 1). that injury or attenuation of the ul- et al5 in 1981 in a small series of pa- Lichtman and colleagues5-8 de- nar of the palmar arcuate (ie, tients who presented with painful scribed a clinical test, the midcarpal triquetral-hamate-capitate) ligament clunking of the wrist. These patients shift test, to demonstrate this clunk. or the dorsal radiotriquetral liga- had a visible or palpable volar de- The patient’s wrist is positioned in ment is also implicated in symptom- pression or sag at the midcarpal neutral flexion-extension, with slight atic palmar CIND5,6,10,11 (Figure 5).

576 Journal of the American Academy of Orthopaedic Surgeons Scott W. Wolfe, MD, et al

Figure 2

Diagram of the four subcategories of carpal instability nondissociative (CIND) and the nomenclature by which they are often referred. Nonsurgical management is less successful for combined CIND than for palmar or dorsal CIND. Surgical results for adaptive CIND generally are superior to surgical results for the other subcategories of CIND. CIND-DISI = CIND dorsal intercalated segmental instability, CIND-VISI = CIND volar intercalated segmental instability, CLIP = capitolunate instability pattern, ulnar MCI = ulnar midcarpal instability. (Adapted with permission from Garcia- Elias M: The non-dissociative clunking wrist: A personal view. J Hand Surg Eur 2008;33[6]:698-711, except for the radiographs, which are reproduced with permission from Scott W. Wolfe, MD, New York, NY.)

Palmar CIND occurs when these carpal row will remain flexed during in the ulnolunate and ulnotriquetral supportive structures become dys- ulnar deviation until the triquetro- ligaments (Figure 5, A and B). In- functional, either by rupture, attenu- hamate joint becomes engaged and creased tension in these two liga- ation, increased elasticity, or poor the joint-compressive forces across ments resists the extension force on proprioception. The entire proximal that helicoidally shaped articulation the proximal carpal row and causes row rotates into flexion, which force the proximal row to rotate sud- the clunk to occur a bit later in ulnar causes an associated volar transla- denly and abruptly into extension.4,9 deviation, resulting in a more intense tion (ie, volar sag) of the distal car- Forearm pronation accentuates the clunk in pronation than in supina- pal row (Figure 6). The proximal clunk because it increases the tension tion.

September 2012, Vol 20, No 9 577 Carpal Instability Nondissociative

Figure 3 Figure 4

Clinical photograph demonstrating A and B, Illustrations of the wrist going into ulnar deviation (large arrows). volar sag (arrow) of the carpus in a The catch-up clunk (small arrow) occurs when the proximal carpal row shifts patient with left-sided palmar carpal suddenly from flexion into extension as the wrist translates from radial to instability nondissociative. ulnar deviation. B, With the wrist in ulnar deviation, the proximal carpal is (Reproduced with permission from now extended. The dashed outline indicates the extended position of the Scott W. Wolfe, MD, New York, lunate. NY.)

Diagnostic Workup tion and observing for either widen- ing objects with the forearm supi- Most patients with palmar CIND ing of the scaphotrapeziotrapezoid nated.4 As the condition becomes have generalized ligamentous laxity, joint or for palmar capitolunate sub- chronic, the pain and clicking are ac- so it is important to obtain bilateral luxation.12 companied by weakness, as de- wrist radiographs. Plain radiographs scribed in the series of 12 patients may be normal or they may demon- with CCIP of Johnson and Carrera.14 strate varying degrees of the VISI Dorsal CIND Patients with dorsal CIND may re- pattern of lunate volar tilt. Videoflu- port a history of an extension injury oroscopy may be more helpful to The dorsal CIND subcategory en- to the wrist, but this may or may not establish the diagnosis than plain ra- compasses the capitolunate instabil- be causally related. diography. Lateral fluoroscopy cap- ity pattern (CLIP) first described by 13 Louis et al13 described a dynamic tures the maintenance of the volar- Louis et al in 1984 and the chronic flexed position of the proximal row capitolunate instability pattern dorsal displacement test to diagnose as the wrist moves from radial to ul- (CCIP) described by Johnson and patients with CLIP or dorsal CIND. 14 nar deviation. Toward the extremes Carrera in 1986. Dorsal CIND is To perform this test, the wrist is of ulnar deviation, the proximal row also referred to as CIND-DISI be- placed in flexion, and ulnar devia- suddenly and dramatically snaps into cause, in this variant, the clinical tion and longitudinal traction are ap- extension.4 clunk occurs secondary to dorsal plied. Dorsally directed pressure is Stress views can also be performed subluxation of the capitate from the then placed over the scaphoid tuber- under fluoroscopy to assess for pal- dorsally tilted proximal carpal row cle, which causes simultaneous dor- mar CIND. A lateral view in neutral, in ulnar deviation. Dorsal CIND is sal subluxation of the proximal row radial, and ulnar deviation demon- less common than palmar CIND. and dorsal subluxation of the capi- strates the extremes of lunate pos- tate from the lunate (Figure 7). In a ture. The anterior drawer stress view Clinical Presentation positive test, this degree of dorsal can be performed by translating the Patients with dorsal CIND typically subluxation reproduces the patient’s distal carpal row in a palmar direc- report pain and clicking while grasp- pain.

578 Journal of the American Academy of Orthopaedic Surgeons Scott W. Wolfe, MD, et al

Figure 5 normally aligned in dorsal CIND. In dorsal CIND, the clunk occurs in ul- nar deviation because the capitate subluxates dorsally from its reduced resting position. There is some uncertainty regard- ing the specific ligaments responsible for dorsal CIND. Louis et al,13 who first described CLIP, hypothesized that dorsal subluxation of the capi- tate occurs secondary to laxity of the radiolunate ligaments, the dorsal capitolunate ligament complex, and the extrinsic stabilizers of the scaph- oid (Figures 4 and 5, A and B). John- son and Carrera,14 who described CCIP, theorized that dorsal capitate subluxation occurs secondary to posttraumatic attenuation of the pal- mar radiocapitate ligament. Most likely, there is a combination of fac- tors explaining this type of instabil- ity. Underdevelopment or increased laxity of the dorsal intercarpal liga- ment (Figure 5, C and D), particu- larly the thick scaphotriquetral fasci- cles, and excessive laxity of the space of Poirier are two major factors that contribute to dorsal CIND. The scaphotriquetral fascicles of the dor- sal intercarpal ligament act as a Illustration (A) and clinical photograph of a cadaver specimen (B) pseudolabrum, deepening the ball- demonstrating that the ulnar arm of the palmar arcuate ligament (panel A, and-socket–like articulation of the shaded in red; panel B, yellow arrows) is implicated in palmar carpal instability nondissociative (CIND). Illustration (C) and clinical photograph of a scapholunocapitate joint and pre- cadaver specimen (D) demonstrating that the dorsal radiotriquetral ligament venting subluxation. Deficiency of (panel A, shaded in red; panel B, yellow arrow) is also implicated in palmar the dorsal intercarpal ligament and CIND. C = capitate, DIC = dorsal intercarpal ligament, H = hamate, attenuation of the long radiolunate L = lunate, LRL = long radiolunate ligament, P = pisiform, RS = radioscaphoid ligament, RSC = radioscaphocapitate ligament, and the radioscaphocapitate liga- RSL = radioscapholunate ligament, RT = radiotriquetral ligament, ments (the two margins of the space S = scaphoid, SRL = short radiolunate ligament, T/Tq = triquetrum, of Poirier) allow the capitate to sub- UC = ulnocapitate ligament, UL = ulnolunate ligament, UT = ulnotriquetral ligament. (Panels A and C adapted with permission from Lichtman DM, luxate dorsally when the proximal Wroten ES: Understanding midcarpal instability. J Hand Surg Am 2006;31[3]: row extends during ulnar deviation. 491-498. Panels B and D reproduced with permission from Scott W. Wolfe, MD, New York, NY.) Diagnostic Workup In dorsal CIND, plain radiography Pathomechanics and dorsal CIND conditions are and arthrography are not typically In patients with normal wrist kine- both characterized by the lack of helpful. Occasionally, lateral wrist matics, the proximal carpal row these smooth transitions secondary radiographs may demonstrate a moves smoothly into extension, and to carpal ligament dysfunction.4 In slight dorsal tilt to the lunate. Fluo- the distal carpal row translates dor- contrast to the initial volar sag of roscopy is critical for the diagnosis sally with ulnar deviation. Palmar palmar CIND, the carpus is often of dorsal CIND.

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Figure 6 Figure 7

Illustration demonstrating the palmar translation of the capitate (C) and the flexion of the lunate (L, shaded) that are characteristic of A, Illustration of the dorsal capitate-displacement test. The examiner applies patients with palmar carpal longitudinal traction and mild flexion to the wrist while applying dorsally instability nondissociative (CIND) directed pressure to the scaphoid tubercle (arrow). This pressure causes the when the are in a neutral dorsal subluxation of the capitate and the proximal row. B, Lateral radiograph position. In palmar CIND, the head demonstrating both dorsal subluxation of the capitate (top double arrow) on of the capitate translates palmarly, the lunate and dorsal subluxation of the proximal row (lunate) (bottom double and the proximal carpal row arrow) on the distal radius during a dorsal capitate-displacement stress test remains flexed until the extremes in a patient with dorsal carpal instability nondissociative. C = capitate, of ulnar deviation, when the L = lunate, R = radius, S = scaphoid. (Panel B reproduced with permission triquetrohamate joint is re-engaged from Scott W. Wolfe, MD, New York, NY.) and the proximal row clunks into extension. R = radius. (Adapted with permission from Garcia-Elias stability at the capitolunate joint Clinical Presentation M: The non-dissociative clunking reproduces the patient’s pain and Combined CIND is more common in wrist: A personal view. J Hand Surg clunking.15 Eur 2008;33[6]:698-711.) females than males, and it often pre- sents in teenage girls with gener- Combined CIND alized ligamentous laxity. In addi- The diagnosis of dorsal CIND can tion to hyperlaxity, these patients be made using the dorsal capitate- The combined subcategory of CIND often have a history of an extension displacement stress test;13 this ma- was first described by Apergis16 in injury to the wrist. They typically neuver involves performing the dy- 1996 in a series of 14 patients with present after playing sports that in- namic dorsal displacement test under chronic wrist pain, vague numbness, volve repetitive gripping or striking, videofluoroscopy. As demonstrated and reduced grip strength. These pa- such as volleyball, tennis, and gym- in Figure 7, the examiner applies tients demonstrated volar sag of the nastics. dorsally directed pressure to the carpus on visual inspection sugges- Patients with combined CIND scaphoid tubercle with the wrist in tive of palmar CIND and also had demonstrate signs of both palmar flexion. Videofluoroscopy demon- positive dorsal displacement tests and dorsal CIND on physical exami- strates dorsal subluxation of the cap- with dorsal subluxation noted on nation. They have markers of overall itate. The diagnosis is made when in- videofluoroscopy. ligamentous laxity, such as hyperex-

580 Journal of the American Academy of Orthopaedic Surgeons Scott W. Wolfe, MD, et al tension of the and thumbs. that are extrinsic to the carpus. The and the normal force transmission Volar sag of the ulnar carpus may be classic example of adaptive CIND across the carpus and extrinsic mus- noted on inspection, and both the occurs following a malunited distal culotendinous units is altered. dorsal and palmar displacement tests radius fracture. The pattern was first are positive. described by Linscheid et al17 in Diagnostic Workup 1972. Taleisnik and Watson18 pre- Plain radiographs typically demon- Pathomechanics sented a series of 13 patients with in- strate a malunited distal radius with The instability in combined CIND stability and pain at the midcarpal a dorsal tilt. The patients reported typically results from attenuation or joint secondary to distal radial on by Taleisnik and Watson18 had an congenital laxity of both the volar malunions in 1984, for which the average dorsal tilt of 23° of the ra- and dorsal carpal ligaments. In many term extrinsic instability was used. dial articular surface. The capitate is instances of combined CIND, there flexed relative to the lunate and posi- are also features of radiocarpal insta- Clinical Presentation tioned dorsal to the longitudinal axis bility, with increased subluxation at of the proximal radial shaft.18 Patients with adaptive CIND present that level. with clunking or snapping of the In radial deviation, the proximal wrist in ulnar deviation with the carpal row is flexed and ulnarly Management forearm pronated. They typically translated. With ulnar deviation, the have tenderness to palpation at the Management of CIND is primarily lunate clunks into extension, similar capitolunate and triquetrohamate nonsurgical. Patients with general- to palmar CIND. In addition, ex- joints. In the classic case, the patient ized laxity may present with a pain- tremes of ulnar deviation cause dor- provides a history of having sus- less clinical clunk secondary to sal subluxation of the capitate, simi- tained a distal radius fracture. Ra- CIND. These patients require no lar to dorsal CIND. Most patients diographs demonstrate a dorsal treatment unless they develop pain with combined CIND have an in- malunion of the distal radius. or dysfunction. creased distal radial inclination in For symptomatic patients, nonsur- the frontal plane and -minus Pathomechanics gical management is typically suc- variance.4 Though seemingly associ- cessful. Treatment should include pa- ated, it is unclear what role these In adaptive CIND conditions, the volar tient education on the nature of the two factors play in the pathome- carpal ligaments are effectively slack- problem and, occasionally, splinting, chanics of combined CIND. ened and are less capable of inducing the physiologic shift of the proximal anti-inflammatory medications, and short courses of hand therapy. For Diagnostic Workup carpal row from flexion into extension as the wrist ulnarly deviates. The car- refractory cases, surgical manage- As with palmar and dorsal CIND, pal ligaments are not typically torn or ment may be attempted, but out- videofluoroscopy is the most helpful attenuated, but the distances between comes are not predictable. Surgical diagnostic tool for confirming a their origins and insertions are de- management of each CIND subcate- combined pattern of CIND. Bilateral creased by the dorsal tilt of the gory varies to address the specific radiographs are particularly impor- malunited distal radius and compensa- sites of pathology implicated in each tant in this group of patients, given tory jackknife extension of the proxi- group. Results are better for the sub- their high incidence of generalized mal row and flexion of the distal car- categories in which the pathome- ligamentous laxity. An increased ra- pal row. The decreased distances result chanics are better understood. dial inclination of the distal radius in insufficiently taut ligaments that are articular surface and ulna-minus incapable of preventing dorsal transla- Palmar CIND variance may be noted on plain ra- tion of the capitate and distal carpal Initial management of palmar CIND diographs.12 row.4 is nonsurgical; most patients respond In lateral radiographs of adaptive to such management alone. Non- Adaptive CIND CIND secondary to dorsal malunion steroidal anti-inflammatory drugs of the distal radius, the lunate is typi- and activity modification are typi- Unlike the other three subcategories cally in extension and the capitate is cally helpful to relieve symptoms. A of CIND, adaptive CIND conditions typically in flexion. The capitate and splint with ulnar volar support often are characterized by clunking and in- lunate are not collinear with the lon- helps reduce the symptomatic volar stability secondary to abnormalities gitudinal axis of the proximal radius, sag of the proximal row and main-

September 2012, Vol 20, No 9 581 Carpal Instability Nondissociative

24 Figure 8 scopic thermal capsulorrhaphy and only 6 of 11 cases. Goldfarb et al soft-tissue reconstruction for milder reported that seven of eight patients cases and limited radiocarpal or in- were satisfied with four-corner ar- tercarpal fusions for more severe throdesis and that six of the eight cases. Mason and Hargreaves20 per- had no pain or mild pain after the formed arthroscopic shrinkage of the procedure. volar extrinsic ligaments in 15 wrists Although midcarpal fusions have and reported improved or resolved had reasonable results for palmar instability in all wrists, as well as pa- CIND, the limited carpal motion in- tient satisfaction in 14 of 15 patients herent in these procedures is a matter at 3.5-year follow-up. Long-term re- of concern with patients and may sults after thermal capsulorrhaphy cause functional impairment. The for CIND are unknown. Although importance of maintaining the dart the early results reported by Mason thrower’s motion for recreational, and Hargreaves20 are promising, in- occupational, and household activi- formation from the litera- ties has been increasingly recog- ture about chondrolysis and articular nized.25 Triquetrohamate fusions and cartilage damage with capsulorrha- four-corner fusions correct the clunk phy21,22 should be considered before and posture abnormality associated widespread adoption of this tech- with palmar CIND. However, these nique for management. procedures ablate midcarpal motion Soft-tissue reconstruction options and the dart thrower’s motion, lead- include stabilization of the triquetro- ing to marked loss of ulnar devia- hamate joint by rerouting the exten- tion, an abnormal arc of circumduc- sor carpi ulnaris , advance- tion, and mixed clinical results.23 Clinical photograph demonstrating the use of splints with ulnar volar ment of the ulnar arm of the volar An alternative surgical option pro- support to manage palmar carpal arcuate ligament across the midcar- posed for palmar CIND is radiolu- instability nondissociative. pal joint, reefing of the dorsal ra- nate fusion. Radiolunate fusion sta- (Reproduced with permission from diotriquetral ligament, and double- bilizes the entire proximal row in Scott W. Wolfe, MD, New York, NY.) level tenodesis using a slip of the neutral and prevents the dramatic extensor carpi radialis brevis.4,12 flip in lunate posture that character- Prior to soft-tissue reconstruction, izes this condition12 (Figure 9). Un- arthroscopy or arthrotomy and/or like midcarpal fusion for palmar synovectomy can be performed at CIND, radiolunate fusion preserves tain the lunate in a neutral position19 the discretion of the surgeon. With motion at the midcarpal joint and (Figure 8). Alternatively, and espe- the exception of capsulorrhaphy, preserves the dart thrower’s mo- cially when palmar CIND is unilat- soft-tissue reconstructions have been tion.26,27 Halikis et al27 reported ex- eral and identified following an acute less successful than limited midcarpal cellent pain relief in five patients injury, the affected wrist can be or four-corner fusions for palmar who underwent radiolunate fusion casted for 4 to 6 weeks in neutral CIND.6,23,24 In 1993, Lichtman et al6 for CIND. All patients, including one flexion and ulnar deviation. Hand compared six patients treated with with a nonunion, resolved the therapy should focus on reestablish- limited midcarpal arthrodesis with catch-up clunk. At a minimum 2.5 ing proprioceptive control of the nine patients who were treated with years of follow-up, extension was re- wrist. Isometric strengthening of the one of four different soft-tissue pro- duced by 25% compared with the flexor carpi ulnaris and extensor cedures for palmar CIND. All of the contralateral side. Flexion was re- carpi ulnaris muscles counteracts limited midcarpal arthrodeses were duced by 32%, radial deviation was flexion of the proximal carpal row successful compared with the soft- reduced by 37%, and ulnar deviation by generating a realigning force to tissue reconstruction group, in which was reduced by 33% compared with the pisotriquetral unit.12 six of the nine procedures failed. Rao the contralateral side.27 Garcia- When many months of conserva- and Culver23 reported less favorable Elias12 reported good preliminary re- tive management have failed, surgi- outcomes with limited midcarpal fu- sults in a small series of nine patients cal treatment options include arthro- sions for this group, with success in with combined CIND who exhibited

582 Journal of the American Academy of Orthopaedic Surgeons Scott W. Wolfe, MD, et al

Figure 9

Radiolunate fusion preserves the dart thrower’s motion and is a suitable management option for recalcitrant palmar CIND and combined CIND. A, PA radiograph demonstrating radiolunate fusion stabilized with Kirschner wires. PA (B) and lateral (C) radiographs demonstrating a radiolunate fusion stabilized with compression screws. D, PA radiograph demonstrating a radiolunate fusion after hardware removal. (Reproduced with permission from Scott W. Wolfe, MD, New York, NY.)

features of radiocarpal and midcar- Dorsal CIND years and 4 months. The lunate and pal instability. Six were stabilized Similar to palmar CIND, dorsal capitate were stabilized by their pro- with Kirschner wires, and three were CIND usually responds to nonsurgi- cedure, but they reported some loss stabilized with two crossed compres- cal management.4 However, Ono of wrist extension. There is insuffi- sion screws (Figure 9). One patient et al28 reported on a group of five pa- cient evidence at this time to deter- developed a nonunion that required tients for whom nonsurgical manage- mine what role, if any, radiolunate reoperation. At an average follow-up ment did not provide sustained, fusion may have in the management of 19 months, all patients had nor- long-term relief. In refractory cases, of dorsal CIND. mal grip strength and had returned palmar ligament reefing and/or dor- to their previous occupations. Combined CIND Clunking resolved in all patients. sal intercarpal capsulodesis have Compared with the contralateral both been used successfully. Johnson Although activity modification and 14 side, there was an average reduction and Carrera treated 11 of the 12 nonsurgical management should be of 32% flexion-extension motion.12 patients in their CCIP series by sutur- the initial line of management, pa- Further studies on the use of radiolu- ing the volar radioscaphocapitate lig- tients with combined CIND may not nate fusion for managing CIND are ament to the long radiolunate liga- respond as well to nonsurgical man- warranted, but the preservation of ment and closing down the space of agement as do those with the iso- the dart thrower’s motion suggests Poirier. They reported good to excel- lated palmar or dorsal variants. In that this technique will be successful lent results in nine patients, fair re- the series reported by Apergis16 in in preserving function while elimi- sults in one, and poor results in one 1996, none of the 14 patients with nating instability. at an average follow-up time of 4 combined CIND responded to non-

September 2012, Vol 20, No 9 583 Carpal Instability Nondissociative surgical management. Radiolunate fusion, as described Combined CIND can be managed above, is also an attractive option for Summary with soft-tissue or bony procedures. combined CIND. For example, CIND represents a spectrum of dis- Apergis16 treated all 14 patients in Garcia-Elias12 reported excellent orders associated with wrist pain, of- his series with ligamentous reefing. early results in nine patients. Radio- ten with clunking that is caused by On the volar radial side, he sutured lunate fusion provides stability and instability at the midcarpal and/or the volar radioscaphocapitate liga- eliminates the clunk without interfer- radiocarpal joints. Despite the results ment to the long radiolunate liga- ing with midcarpal motion. Patients of cadaver and clinical studies, the ment. On the ulnar side, he sutured with combined CIND tend to be pathomechanics responsible for most the triquetrocapitate ligament to the younger, so preserving motion and lunotriquetral ligament. He reported of the CIND disorders are incom- function is particularly important in good to excellent results in 13 pa- pletely understood. In general, non- this group. tients and a fair result in 1 patient. dissociative instability is thought to occur because of congenital, adap- No recent case series are available. Adaptive CIND Wright et al2 published a retrospec- tive, or posttraumatic insufficiency tive review of 45 patients with The pathomechanics responsible for of various intrinsic and extrinsic car- CIND. Seven patients were treated adaptive CIND are well understood. pal ligaments. Four types of CIND nonsurgically and 38 were treated Surgical management is aimed at cor- have been described: palmar, dorsal, surgically with soft-tissue reconstruc- recting the extrinsic deformity re- combined, and adaptive. Radiocar- tions, joint-leveling osteotomies, or sponsible for effectively slackening pal instability, including ulnar trans- midcarpal fusions. Although not the palmar ligaments. In the case of lation, can be dissociative or nondis- clearly stated, most of the patients in adaptive CIND secondary to a sociative and does not fit entirely their series appeared to have symp- malunited distal radius fracture, the within the CIND category from an toms consistent with combined treatment of choice is a corrective os- etiologic or management perspective. CIND, with evidence of both dorsal teotomy to restore the normal volar CIND typically responds to nonsur- and volar instability on provocative tilt of the distal radius. Correction of gical management. When nonsurgi- maneuvers. The authors excluded the bony anatomy has the potential cal management fails, surgical op- patients with adaptive CIND second- to realign the lunate and capitate tions for palmar CIND include ary to distal radius malunions. In with the longitudinal axis of the ra- arthroscopic thermal capsulorrha- this series, only 56% of patients had dius, thereby removing the tendency phy, soft-tissue reconstruction, or good or excellent results. The best for dorsal tilt of the lunate and com- limited radiocarpal or intercarpal fu- results were in the subgroup of six pensatory flexion of the capitate. In sions (Figure 2). Refractory cases of patients who were treated with joint- addition, realignment of the bony dorsal CIND respond to palmar liga- leveling osteotomies for CIND asso- anatomy rebalances the tension of ment reefing and/or dorsal intercar- ciated with ulna-minus variance. the extrinsic ligaments, the capsule, pal capsulodesis. Combined CIND Eighty-three percent of the patients and the extrinsic muscle tendon can be treated with either soft-tissue with preoperative ulna-minus vari- forces, thus stabilizing the carpus. In or bony procedures. Treatment of ance had good or excellent results af- chronic cases, however, adaptive car- choice for adaptive CIND is a cor- ter joint-leveling osteotomy. The ra- pal malalignment is generally incom- rective osteotomy to restore the nor- tionale for surgical success in this pletely corrected by osteotomy. mal volar tilt of the distal radius. subgroup is not completely under- Overall, the results from surgical stood, but the authors noted that management of adaptive CIND tend they could eliminate the clunk in to be superior to the results for the References these patients preoperatively by pro- other subcategories of CIND. This is viding ulnar-sided pressure. They likely because of our increased un- Evidence-based Medicine: Levels of theorized that joint-leveling proce- derstanding of the pathomechanics evidence are described in the table of dures might restore ulnar-sided sup- responsible for adaptive CIND, contents. In this article, reference 8 is port by tensioning ligamentous stabi- which allows us to better target our a level II study. References 2, 6, 10, lizers, thus facilitating a smooth surgical management, as well as the 16, 20, and 22 are level III studies. transition of the proximal carpal row absence of generalized ligamentous References 1, 5, 11, 13-15, 18, 19, as the wrist moves from radial to ul- laxity, which can confound soft- 21, 23, 24, 26, and 28 are level IV nar deviation.2 tissue stabilization procedures. studies. References 3, 4, 7, 9, 12, 17,

584 Journal of the American Academy of Orthopaedic Surgeons Scott W. Wolfe, MD, et al

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